This practical guide provides the perspectives needed to treat acute and chronic pain in the hospital.
Authored by experts of diverse specialty backgrounds, chapters bring the available evidence together with modern strategies for caring for patients with complex pain. Basic considerations and multimodal and multidisciplinary approaches with the greatest impact on minimizing suffering and burden of care are covered in detail.
The material in this text will assist the learner, the teacher, and the life-long learning practitioner by providing basic considerations for treating acute and chronic pain in the hospital. This book may also serve as a quick reference, review manual or teaching tool by teachers on rounds.
Author(s): David A. Edwards, Padma Gulur, Christopher M. Sobey
Publisher: Springer
Year: 2022
Language: English
Pages: 248
City: Cham
Preface
Contents
Contributors
Abbreviations
1: Introduction to the Chronic Pain Patient
Introduction
References
2: Definitions
Introduction
Reference
Part I: Pathophysiology
3: Acute Pain
Relationship of Acute Pain to Chronic Pain
Mechanism of Acute Pain
Treatment of Acute Pain
References
4: Chronic Pain
Prevalence and Risk Factors
Pathophysiology of Chronic Pain
Phase I: Acute Surgical Response and Acute Pain
Phase II: Centralized Chronic Pain
Prevention and Treatment Principles of Chronic Pain
Conclusion
References
5: Opioid-Induced Hyperalgesia
Clinical Examples of OIH
Remifentanil
Methadone
Mechanism Underlying OIH
References
Part II: Admission and Consultation
6: History
History of Presenting Illness
Pain Assessment Tools
Functional Status
Past Medical History/Past Surgical History
Medication List
Review of Systems
Psychological History
Special Considerations
Implantable Pain Devices: Spinal Cord Stimulator and Intrathecal Drug Delivery Device
Post-Surgical Patients
Patients with an Epidural
Patients with a Peripheral Nerve Block
Summary
7: Physical Examination
Goals of the Exam
Vital Signs
Head and Neck Evaluation
Neurological Examination
Skin Examination
Cardiovascular Examination
Respiratory Examination
Abdominal Examination
Genitourinary Examination
Extremity Examination
Musculoskeletal Examination
Examination of Surgical Site
Examinations of Epidural Analgesia
Examination of Peripheral Nerve Blocks
Summary
References
8: The SCRIPT History Template
Introduction
Pain Red Flags
References
9: Patient Reported Outcomes
Patient Reported Outcomes
PROs in the Hospitalized Chronic Pain Patient
General Strategy
Frequency of Administration
Specific Choice of Instrument
Domain Selection
Daily Instruments (Table 9.2)
Longitudinal Instruments
NIH’s Patient Reported Outcomes Measurement Information System (PROMIS—www.healthmeasures.net)
Conclusion
References
10: Clinical and Experimental Tools for Measuring Pain
Introduction
QST Methodology
Stimulus Modalities and Target Tissues
QST Response Measures
Static
Dynamic
Clinical Relevance
Predicting Clinical Pain
Predicting Treatment Responses
Conclusion
References
Part III: Cases
11: Case 1: High Dose Opioids and Multiple Pain Medications
Considerations for Treatment of Acute on Chronic Pain
High Dose Opioids
Multimodal Analgesia
Co-Morbid Conditions and Risk of Overdose
References
12: Case 2: Buprenorphine
Background
Pharmacology
Buprenorphine Formulations
Buprenorphine Management for Surgery
Regional and Neuraxial Anesthesia
Option 1: Elective Surgery: Continue Buprenorphine Therapy, Consider Dose Reduction
Option 2: Urgent/Unexpected Surgery: Use Clinical Judgment
Case Discussion
References
13: Case 3: Methadone
Pharmacology
Methadone Indications
Methadone and QTc
References
14: Case 4: Abdominal Pain
Abdominal Wall Pain
Chronic Pancreatitis
Inflammatory Bowel Disease
Gastroparesis
References
15: Case 5: Unknown Pain Source
Fibromyalgia
Conservative and Alternative Management
Pharmacologic Management
Temporomandibular Joint Disorder
Conservative Management
Pharmacologic Management
Interventional and Surgical Management
Functional Abdominal Pain and Irritable Bowel Syndrome
Conservative Management
Pharmacologic Management
Interstitial Cystitis
Conservative Management
Pharmacologic Management
Interventional and Surgical Management
Chronic Pelvic Pain
Pharmacologic Management
Interventional Management
References
16: Case 6: Sickle Cell Disease
Background
Symptom Clinical Manifestations
Acute Care Presentation Triage
Management of Acute Pain Crisis
Non-Opioid Analgesia Recommendations
Role for Opioid Use for Acute Management of Pain
Conversion Towards Chronic Pain
Chronic Opioid Therapy
Comorbid Psychological Disturbances
Treatment Challenges
References
17: Case 7: A Cancer Pain Crisis
Treatments and Care Plan
Outcome
Multidisciplinary Approach and Considerations [5, 6]
References
18: Case 8: Spasticity and Pain
Treatments and Care Plan
Multidisciplinary Approach and Considerations
References
19: Case 9: Renal and Hepatic Disease
Pharmacologic Impact of Renal Impairment
Hepatic Disease
References
20: Case 10: Chronic Pain Patient After Spine Surgery
Review of Recent Literature
Treatments and Care Plan
Multimodal Therapy
References
21: Case 11: Angry Patient
Evidence Based Approaches for Difficult Encounters
Treatments and Care Plan
Approaching the Difficult Patient
References
22: Case 12: Intrathecal Pain Pump
Background
MRI Compatibility
Alarming Pump
Intrathecal Infusion Considerations
Case Scenario
References
23: Case 13: Spinal Cord Stimulation
Background
Risks
Scenario Treatment Recommendations
References
24: Case 14: Opioid Use Disorder
Introduction
What Opioids Do to the Brain
What Happens to People with an Addiction to Opioids
Vulnerability to OUD and Co-Occurring Psychiatric Disorders
The Best Way to Treat Opioid Addiction
Recovery from Opioid Addiction
Stigma: An Attribute, Behavior, or Condition That Is Socially Discrediting
Opioid Withdrawal Symptoms
Important Points to Remember (Tables 24.5, 24.6 and 24.7)
Acute Pain Management in Patients Taking Buprenorphine for MAT
Treating the Pregnant Patient
References
25: Case 15: Comorbid Psychological Condition
Literature Review
Case Scenario Care Plan
References
26: Case 16: Poor Prognosis in a Palliative Care Patient
Treatments and Care Plan
References
27: Case 17: Management of a Pain/Dyspnea in an Actively Dying Patient
Outcome
References
Part IV: Medication Treatments
28: Opioids
Common Opioids
Opioid Cross-Tolerance
Opioid Conversion
Opioid Metabolites
Opioid Rotation
Opioid Addiction
References
29: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Background
Types of NSAIDs
Benefits
Adverse Effects
References
30: Acetaminophen
Mechanism of Action
Administration
Dosage
Contraindications
References
31: Local Anesthetics
What Are Local Anesthetics?
Mechanism of Action
Pharmacokinetics
Metabolism
Why Use Local Anesthetic Regional Techniques for the Chronic Non-cancer Patient With Acute Pain?
Why Use Intravenous Lidocaine for the Chronic Non-cancer Patient with Acute Pain?
What Are the Risks of Local Anesthetic Administration?
Local Anesthetic Systemic Toxicity
References
32: NMDA Antagonists
Introduction
Routes
Side Effects/Toxicity
Conclusion
References
33: Alpha-2 Agonists
What Are Alpha-2 Agonists?
Clonidine
Metabolism
Tizanidine
Metabolism
Dexmedetomidine
Metabolism
Guanfacine
Metabolism
References
34: Gabapentin and Pregabalin
Basics
Mechanism of Action
Dosing
Adverse Effects
References
35: Tricyclic Antidepressants and Serotonin-Norepinephrine Reuptake Inhibitors
Tricyclic Antidepressants
Initiation and Side Effects
Serotonin-Norepinephrine Reuptake Inhibitors
Duloxetine
Milnacipran
Venlafaxine/Desvenlafaxine
Continuation as Inpatient
References
36: Steroids
Endogenous Steroids
Role of Steroids in Pain
Inflammatory Pain
Neuropathic Pain
Steroids in Cancer and Associated Conditions
Administration
Side Effects
References
37: Cannabinoids
Background
Public and Mental Health Concerns
References
Part V: Interventional Treatments
38: Peripheral Regional Anesthesia Blocks
Introduction
Complications/Precautions
References
39: Neuraxial Blocks
Anatomy
Technique
Pharmacology
Physiological Response
Side Effects and Complications
Conclusion
References
40: Vertebroplasty and Kyphoplasty
Background
Literature Review
Treatments and Care Plan [1]
Multidisciplinary Approach and Considerations
Case Result
Summary
References
41: Surgical Interventions for Pain
Low Back Pain
Osteoarthritis/Rheumatoid Arthritis
Cancer-Related Musculoskeletal Pain
References
Part VI: Palliative Care
42: Opioid and Non-opioid Therapies in Palliative Care
Non-opioid Therapies
NSAIDs
Corticosteroids
Neuropathic Agents
Cannabinoids
Opioid Therapies
Titration and Rotation
Opioid Side Effects
Constipation
Nausea and Vomiting
Sedation/Delirium
References
43: Crisis Management and Refractory Pain
Assessment of a Patient in a Pain Crisis
Management of a Pain Crisis
Opioids
Route
Starting Doses
Titrate Based on Response
Non-opioid Adjuvant Medications
Refractory Pain
Assessing for Psychological Distress
References
Part VII: Discharge
44: Transition to Outpatient Care and Readmissions
Transition to Outpatient Care of the Surgical Patient
Transition to Outpatient Care of the Medical Patient
Special Considerations: Use of Controlled Substances
Special Considerations: Caregiver and Family Support
References
45: Opioid Tapering for Acute on Chronic Non-cancer Pain
Why Taper Opioids for Patients with Acute on Chronic Non-cancer Pain?
When to Taper Opioids for Acute on Chronic Non-cancer Pain
How to Taper Opioids for Acute on Chronic Non-cancer Pain
Consequences of Opioid Tapering
Withdrawal
Worsening Pain
Conclusions
References
Index
